As a result of the latest enforcement survey issued by the Department of Health, Wingate at Beacon, a Dutchess county nursing home, was fined $24,000. During a January, 2011 certification survey at Wingate, the DOH found four deficiencies serious enough to warrant a severity level of Immediate Jeopardy. This is the most severe rating that the DOH dispenses in its certification surveys. The four deficiencies each centered around the death of a resident after choking on her food.

As mentioned, the Department of Health cited Wingate for four health deficiencies. These areas were:

maintaining a facility free of accident hazards;

administering the facility to obtain the highest practicable well-being of residents;

The resident involved in this unfortunate occurrence was forty-six years old. She suffered from Multiple Sclerosis, Seizure Disorder, and difficulty swallowing. These conditions made her a choking risk. In fact, the resident did choke in December of 2009, requiring the administering of the Heimlich Maneuver. Per physician’s orders, the resident was to be assisted with eating by the facility staff. She was also to be fed a special diet of soft foods with strict monitoring to prevent aspiration (choking by way of inhaling food into one’s lungs). Despite these known risks, and in contravention of the care plan and physician’s orders, the patient was left to feed herself during breakfast one morning. Not only was she left alone, but she was also given a hard boiled egg rather than the “ground diet with extra gravy” per the facility’s stated interventions. As a result of this lapse in judgment by Wingate, the resident aspirated the hard boiled egg, resulting in her death.

Of course, the death of a resident is the most serious and tragic outcome that can arise from facility negligence. Also disturbing in this case is that Wingate was home to more than ninety additional residents suffering from swallowing difficulties. Obviously the potential for serious harm existed for these individuals as well. Again, as is so often the case in situations like this, the tragic events surrounding this resident underscore the importance of a facility diligently following an individualized care plan and physician’s orders. Failure to do so not only leaves the facility open to liability, but also can potentially lead to the unthinkable–the untimely and unnecessary death of one of the residents in its care.

To read further about the incident at Wingate and the Department of Health’s response, go to the entire detailed deficiency report located here.